Risk factors for deep surgical site infection after posterior cervical spine surgery in adults: a multicentre observational cohort study

Construction and validation of a nomogram predictive model for assessing the risk of surgical site infections following posterior lumbar fusion surgery

Surgical site infections (SSIs) are a significant concern following posterior lumbar fusion surgery, leading to increased morbidity and healthcare costs. Accurate prediction of SSI risk is crucial for implementing preventive measures and improving patient outcomes. This study aimed to construct and validate a nomogram predictive model for assessing the risk of SSIs following posterior lumbar fusion surgery. A retrospective study was conducted on 1015 patients who underwent posterior lumbar fusion surgery at our hospital from January 2019 to December 2022. Clinical data, including patient demographics, comorbidities, surgical details, and postoperative outcomes, were collected. SSIs were defined based on the Centers for Disease Control and Prevention (CDC) criteria. Univariate analysis identified significant risk factors, which were then included in a binary logistic regression to develop the nomogram. The model's performance was evaluated using the concordance index (C-index), calibration curves, and receiver operating characteristic (ROC) curves. The incidence of SSIs was 5.02% (51/1015). The most common pathogens were Staphylococcus aureus and Escherichia coli. Significant risk factors for SSIs included smoking history, diabetes, surgery duration ≥ 3 h, intraoperative blood loss ≥ 300 ml, ASA classification ≥ 3, postoperative closed drainage duration ≥ 5 days, incision length ≥ 10 cm, BMI ≥ 30 kg/m2, and the presence of internal fixation. The nomogram demonstrated a C-index of 0.779 and an AUC of 0.845, indicating high predictive accuracy. The calibration curve closely matched the ideal curve, confirming the model's reliability. The constructed nomogram predictive model demonstrated high accuracy in predicting SSI risk following posterior lumbar fusion surgery. This model can aid clinicians in identifying high-risk patients and implementing targeted preventive measures to improve surgical outcomes.

Complications in Occipitocervical Surgery

The occipitocervical junction is formed by the foramen magnum (FM) and the adjacent anatomical structures of the C1 and C2 vertebrae. The FM is formed anteriorly by the basilar part of occipital bone. Anterolaterally, it borders the occipital condyles and hypoglossal canal as well as the jugular foramen. Posteriorly, the FM is formed by the squamous part of the occipital bone with the internal occipital crest. In the midline, named landmarks at the anterior margin are the basion and, at the posterior margin, the opisthion. Vital anatomic structures are located in the FM or pass through. Among these are the medulla oblongata, meninges, anterior and posterior spinal arteries, vertebral arteries, and spinal roots of the accessory nerve. The FM is firmly anchored to the cervical canal via strong ligamentous support.Pathologies in this area can be of congenital, acquired, traumatic, neoplastic, or infectious origin, with the respective surgical indications and approaches depending on the nature and location of the pathology. If the pathology is occipitoatlantal, the occiput is usually involved in surgery. On the other hand, if the pathology is only at the level of C1-C2, surgery may be limited to these two vertebrae.In this section, we present the surgical management of exemplary congenital cases, and we discuss the complications and what needs to be done to deal with them.

Cervical spine infection arising from chronic paronychia: A case report and review of literature

BACKGROUND

Cervical spine pyogenic infection (CSPI) is a rare and challenging form of spinal infection that is typically caused by pyogenic bacteria and primarily affects the cervical vertebral bodies and surrounding tissues. Given its nonspecific symptoms, such as fever and neck pain, early diagnosis is crucial to prevent severe complications, including spinal cord injury. We report a previously unreported case of acute CSPI arising from chronic paronychia, exploring its diagnostic and therapeutic challenges through a review of the current literature.

CASE SUMMARY

The presented case involved a 15-year-old man with CSPI caused by Staphylococcus aureus, which led to complications including bacteremia and a paronychia-associated abscess. Acute pyogenic infection was initially diagnosed by typical symptoms and blood culture. Fever improved after antibiotic treatment while developing progressive limbs dysfunction. Six days after admission, the patient underwent anterior cervical debridement + autogenous iliac bone graft fusion + plate internal fixation and received 12 weeks of antibiotic treatment after the operation. Re-examination 3 years postoperatively showed that the patient had stable cervical fixation, no significant neck pain or upper limb abnormalities, and normal urinary function.

CONCLUSION

Early imaging findings, laboratory markers, and timely antibiotic treatment are crucial for CSPI management, preventing complications and facilitating recovery.

Factors related to surgical site infection in spinal instrumentation surgery: a retrospective study in Japan

STUDY DESIGN

A retrospective study.

PURPOSE

To identify factors involved in surgical site infections (SSIs) after spinal instrumentation surgery performed at a single institution.

OVERVIEW OF LITERATURE

SSIs after spinal instrumentation surgery are a serious complication. Despite reports on risk factors for SSIs in spine surgery, limited studies are related to spinal instrumentation surgery.

METHODS

In total, 828 patients (338 males and 490 females; mean age, 65.0 years) who underwent spinal instrumentation surgery from 2013 to 2021 in Kyorin University School of Medicine were retrospectively investigated. Patients were divided into the SSI (group I) and non-SSI (group N) groups. Patient characteristics, comorbidity, laboratory, and surgical factors were investigated. Univariate analysis was performed for each item, and multivariate logistic regression analysis was performed for items with significant differences.

RESULTS

Fifteen patients (1.85%) had SSIs. Univariate analysis revealed significant differences between groups I and N in history of steroid use, serum albumin, C-reactive protein, number of fixed vertebrae, and perioperative blood transfusion. Multivariate logistic regression analysis showed that a history of steroid use (odds ratio [OR], 5.38; 95% confidence interval [CI], 1.41-20.49; p=0.014), serum albumin (OR, 0.34; 95% CI, 0.13-0.84; p=0.020), and perioperative blood transfusion (OR, 5.85; 95% CI, 1.46-23.50; p=0.013) were independent risk factors for SSIs.

CONCLUSIONS

The results of this study indicate that preoperative nutritional intervention, appropriate management of anemia, and intraoperative and postoperative bleeding control may decrease the incidence of SSIs. However, this study has several limitations, including its retrospective design, analysis of a few SSI cases, and inclusion of various surgical approaches and disease types. Future studies that address these limitations are desirable.

Risk Factors for Postoperative Surgical Site Infection in Patients Undergoing Spinal Tumor Surgery

STUDY DESIGN

A retrospective comparative case-control study.

OBJECTIVE

The aim of this study was to determine the risk factors for postoperative surgical site infection (SSI) in patients with spinal tumors requiring reoperation during the perioperative period.

SUMMARY OF BACKGROUND DATA

SSI is a common postoperative complication of spinal surgery. The occurrence of SSI not only increases the mortality rate but prolongs the patient's hospital stay and increases the medical cost.

METHODS

Included in this study were 202 patients with spinal tumors who received surgical treatment between January 2008 and December 2018, of whom 101 patients who developed SSI and underwent secondary surgery were used as the SSI group, and the other 101 patients with no SSI who were matched with the SSI group by age (±10), pathologic diagnosis (malignant/no-malignant), tumor site (C/T/L/S), surgical approach (anterior/posterior/combined), and surgical team were used as the control group. The clinical data of the 202 patients in both groups were analyzed by logistic regression modeling to identify SSI-associated risk factors.

RESULTS

Multivariate logistic regression analysis showed that the revision status ( B =1.430, P =0.028), the number of spinal levels fused ≥4 ( B =0.963, P =0.006), and the use of bone cement ( B =0.739, P =0.046) were significantly associated with the increased risk of developing postoperative SSI.

CONCLUSIONS

This study identified the revision status, the number of spinal levels fused ≥4, and the use of bone cement as independent risk factors for SSI in patients with spinal tumors who underwent reoperation during the perioperative period.

Incidence and risk factors of surgical site infection following cervical laminoplasty: A retrospective clinical study

There are many debates regarding the risk factors of surgical site infection (SSI) following posterior cervical surgery in previous studies. And, till now there is no such a study to examine cervical laminoplasty surgery. From January 2011 through October 2021, a total of 405 patients who were treated with unilateral open-door laminoplasty surgeries were enrolled in this study. We divided the patients into the SSI group and the non-SSI group and compared their patient-specific and procedure-specific factors. Univariate and multiple logistic regression analysis were performed to determine the risk factors. Of the 405 patients, 20 patients had SSI. The rate of SSI found to be 4.93%. There were significant differences between groups in the thicker subcutaneous fat thickness (FT) (p < 0.001), the higher ratio of subcutaneous FT to muscle thickness (MT) (p < 0.001), the higher preoperative Japanese Orthopaedic Association (JOA) Scores (p < 0.003), the decreased preoperative serum albumin (p < 0.001), the more postoperative drainage (p < 0.05) and the longer time of draining (p < 0.001). Logistic regression analysis of these differences showed that the higher ratio of subcutaneous FT/MT, the higher preoperative JOA scores, the decreased preoperative serum albumin and the longer time of draining were significantly related to SSI (p < 0.05). The higher ratio of subcutaneous FT/MT, the higher preoperative JOA scores, the decreased preoperative serum albumin and the longer time of draining are identified as the independent risk factors of SSI in cervical laminoplasty. Identification of these risk factors could be useful in reducing the SSI incidence and patients counselling.

Sex and gender determinants following spinal fusion surgery: A systematic review of clinical data

In the last decade, numerous studies analyzed and described the surgical outcomes in male and female patients submitted to orthopedic surgery. Although this, the impact of sex/gender on spinal fusion surgery clinical outcomes is still poorly defined. This review systematically maps and synthesizes the scientific literature on sex/gender differences in postoperative outcomes for patients undergoing spinal fusion surgery. The search was performed in PubMed, Scopus, and Web of Science in the last 22 years. Clinical studies evaluating potential sex/gender differences in postoperative outcomes and/or complications, as primary or secondary aim, were included and analyzed. Out of the 1,885 records screened, 47 studies were included. These studies comprised a total of 1,158,555 patients (51.31% female; 48.69% male). About 77% of the analyzed studies reported sex/gender-related differences in postoperative outcomes. Most studies treated patients for lumbar degenerative diseases and more than 55% of them reported a worse postoperative outcome in female patients in terms of pain, disability, health-related quality of life questionnaires, and complications. Differently, a significant heterogeneity across studies on patients treated for cervical and sacral degenerative diseases as well as for spinal deformity and traumatic spinal fracture prevented the understanding of specific sex/gender differences after spinal fusion surgery. Despite this, the present review highlighted those female patients treated for lumbar degenerative spine diseases could require more clinical awareness during postoperative care. The understanding of how sex/gender differences can really affect clinical outcomes after spinal fusion surgeries is mandatory for all spinal pathological conditions to drive clinical research toward oriented and personalized protocols.

C-arm contamination of the surgical field: Can contamination be reduced with an intervening drape?

INTRODUCTION

Contamination of the surgical field by the C-arm in orthopaedic procedures is a significant potential source for surgical site infections. The purpose of this study was to explore the utility of a split sheet to aid in prevention of secondary contamination from the C-arm on the C-arm side of the operative field.

METHODS

A C-arm and a surgical table were draped by standard techniques. The surgical table was split in thirds: the surgeon's side, the C-arm side of the operative field, and the middle for contamination analysis. Fluorescent powder was used to simulate a contaminant and placed on the C-arm, floor and lower portions of drapes. The C-arm was cycled between PA and Lateral positions. Powder transfer to the field was visualized with a camera under uniform UV light. Photographs were taken to measure fluorescent pixels prior to cycling the C-arm and at 5, 10 and 15 cycles. This protocol was repeated using a split sheet (U-drape) to isolate the C-arm below the operative field. Image J was utilized to calculate differences in the number of pixels brighter than the control image.

RESULTS

Using standard draping techniques, there was contamination of the surgical field with the C-arm side of the operative field having the highest level of fluorescent pixels. The number of fluorescent pixels was linearly correlated with the number of PA to Lateral cycles. At the end of 15 cycles, the average number of fluorescent pixels for the intervening draping technique was 2.9 pixels compared to the standard draping technique of 3939 pixels (p = 0.0078).

DISCUSSION

The addition of a U-drape between the C-arm and the table results in a statistically significant reduction in surgical field contamination as a result of secondary transfer from the C-arm.

LEVEL OF EVIDENCE

II.